Universal Naloxone? Experts Say It’s Not that Simple.

Toronto Public Health

Naloxone, the overdose-reversal drug that can bring unconscious opiate addicts back from the brink of death in moments, has been widely heralded as a miracle drug, one that can bring overdose victims back from the dead and that’s credited with saving seven lives since Seattle Police Department bike patrol officers started carrying naloxone nasal spray earlier this year. Daniel Malone, head of the Downtown Emergency Service Center, told me he was “stunned” when he learned that Seattle firefighters, who are all trained as EMTs, don’t carry naloxone; DESC itself has used the drug to reverse about a dozen overdoses since a new state law allowing agencies to get prescriptions for naloxone nasal spray went into effect last year.

Opiates slow down the respiratory system, causing a user to breathe more slowly; they kill when the respiratory system slows down too much and a person nods out, then stops breathing. Naloxone, also known by the brand name Narcan, works by stymieing the impact of heroin on opiate receptors in a person’s brain, allowing a person having an overdse to start breathing on their own.  Since SPD distributed Narcan to 60 bike officers this spring, they’ve reversed seven overdoses with the drug, celebrating each reversal as a “save.”

It’s indisputable that Narcan works. What remains in dispute is whether buying and widely distributing the drug among all first responders, including the entire police, is the best use of limited resources and  political capital, and whether Narcan actually saves as many lives as the Seattle Police Department, under intense pressure to do something to address the heroin epidemic in Seattle, has claimed.

Seattle Fire Department medical Dr. Michael Sayer sighs with exasperation when I ask him why firefighters don’t carry Narcan nasal spray. “Frankly, Narcan doesn’t really save lives,” Sayer says. “To the best of my knowledge, we have had zero cases where someone died because they had an overdose and the EMTs didn’t have naloxone.” That isn’t because Fire Department EMTs do nothing, he says; rather, it’s because EMTs get overdose victims breathing through other means, either by rescue breathing (perhaps better known as mouth-to-mouth resuscitation) or by giving the person oxygen; once they’ve started breathing again, Sayer says, the EMT can start administering a low dose of naloxone through an IV–enough to get the person breathing on their own, but not enough to send them into acute heroin withdrawal. 

“There’s different ways to do a medical intervention; naloxone isn’t the only way,” says Dr. Caleb Banta-Green, a member of the county’s Opiate Addiction Task Force and a UW addiction researcher who’s studying the results of the SPD pilot project. Sitting in his paper-strewn office a few blocks from the UW campus, Banta-Green showed me several different Narcan systems, including two kinds of nasal spray and an injection kit like the one used by SFD. In his observation of fire department medics, Banta-Green says, he saw that “they didn’t just slam [overdose victims] with a bunch of naloxone; they were very careful about how they did it, and they also monitored them really carefully and provided other medical support” to make sure they didn’t immediately go back into an overdose after the drug wore off.

Using Narcan judiciously has another side benefit, Banta-Green and Sayers say; it gives responders a better shot at getting a user to the hospital and potentially connecting him or her with services like treatment and medication.

“If we’re waking up people and we’re putting some fraction of them into withdrawal and then we’re leaving them there, I don’t feel like that’s really solving their problem,” Sayer says. 

Banta-Green is blunt about the shortcomings of an approach that starts and ends with overdose reversal. “Great—so you’ve reversed an overdose. You’ve just bought them 90 minutes. Then what? You still have an opiate-addicted person who’s at continuing risk for overdose.” Waving a bottle of the one-step nasal spray, he continues, “It’s really easy for me to give you this and you go reverse an overdose and [say] we’re good. It’s a lot harder to say to someone, ‘I hear you’re opiate-addicted. Would you like some bupenorphine?” (Bupenorphrine, in combination with naloxone, is sold as the highly regulated addiction maintenance medication suboxone).

“‘Yes, I’d like some bupenorphine,'” Banta-Green continues. “Okay, we need to find you insurance and a medical provider and a pharmacy and figure out a way to keep you on this for the next 20 years. I acknowledge that’s a much harder problem, but that’s the long-term solution.”

Banta-Green says police officers tend to be “stunned” when he tells them naloxone “may or may not be the best intervention,” that the evidence to prove it works better than other interventions just isn’t there yet. Lisa Daugaard, another heroin task force member and director of the Public Defender Association, recalls a conference in Washington, D.C. at which Banta-Green, “Mr. Empirical,” responded to police departments bragging about their number of “saves”—OD reversals that departments count as saved lives—by telling them, “‘You have no idea whether those people would have died. Those aren’t saves—compared to what? Maybe that’s not the most effective thing and maybe most of those people wouldn’t have died if you hadn’t administered naloxone.’ And people were like, ‘Shut the [heck] up, because I don’t want to hear that.'”

Daugaard says that compared to the fire department, which doesn’t have a history of enforcing the punitive war on drugs, SPD may find it “hard to bring a healthy skepticism to bear on specific strategies.  Replacing the instant fix of an arrest with the instant fix of a nasal spray has an appeal that harder, deeper solutions lack.

“This is not to be critical of programs in which officers carry naloxone–I’m not clear what the opportunity costs are,” Daugaard continues. “But I do appreciate first responders who set aside how good it makes them feel to ‘save’ someone and ask harder questions about what is most effective.”

With the jury still out on whether naloxone is a good investment for police in Seattle, everyone I talked to agrees on two types of places where having the spray on hand is a good idea: In the homes of opiate users, and in rural areas, where it may take half an hour for medics to respond to 911.

Banta-Green says his primary concern is choosing the best tools for combating opiate overdose and addiction while people are still paying attention to the “opiate epidemic”—a window that may already be closing. “I’ve worked in this area for 20 years, and it’s so rare that you get to actually talk about addiction or overdose that you want to make sure you have the most impactful way to do it, and that may not be police carrying naloxone. It might be telling people about the good Samaritan laws,” which ensure that people won’t be arrested for drug possession if they report an overdose. “Naloxone has really taken up the vast majority of the attention, and the problem has been that it can deprioritize or even remove attention and funding from other solutions, like syringe exchanges,” Banta-Green says.

In reporting this story, I also talked to one person who is an unequivocal advocate of naloxone distribution, and for very personal reasons: Penny Legate, founder of the Marah Project and the mother of Marah Williams, who died in 2002 at just 19 after fighting heroin addiction for seven years.

Legate says that even if naloxone isn’t a panacea, the risks of not having it on hand outweigh the possibility that overdose victims won’t seek long-term help. “There’s no down side to administering naloxone,” Legate says. “If a person is in a heroin overdose and you have precious minutes to revive them, I don’t know why anyone would object to a police officer or a bystander or anybody administering naloxone. It’s a matter of minutes to return oxygen to the brain.  Are you just going to stand there and say, ‘This person’s not going to get help, we’ve seen it before,’ or ‘Geez, heroin withdrawal is really tough,’ or ‘Let’s just sit here and wait for the medics to show’?”

“The hope,” Legate says, “is that they will allow themselves to be transferred to Harborview, where there are social services available, and that through the process they can be convinced to get help.” But even if many don’t, “is that any reason not to give [the drug] to somebody who isn’t breathing?”